Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it for editing.
2. Begin with the organization information section, where you will select the types of organizational services you offer. Be sure to check all applicable boxes, including hospitals, clinics, or specialized facilities.
3. Fill in the demographics section with the facility’s name, address, city, state, zip code, phone number, fax number, federal tax ID number, and NPI. Ensure accuracy as this information is crucial for your application.
4. Provide the contact details for a representative at your facility, including their name, title, phone number, and email address. If different, include the representative's address.
5. Complete the licensure section by specifying your license type, license number, and expiration date. Answer the question regarding any actions taken against your license appropriately.
6. In the Medicare certification section, indicate whether your facility participates with Medicare and whether it is Medicare certified. Include the Medicare Certification Number and ensure to disclose if your certification is in good standing.
7. Fill out the accreditation details, detailing if you have ARTS or Joint Commission Accreditation and the dates of any relevant surveys. If not accredited, mention your last state or Medicare survey.
8. Provide information about your insurance in the Insurance/Claims section. Include the name of your insurance carrier, policy numbers, levels of coverage, and coverage dates. Ensure you meet the specified minimum coverage requirements.
9. Review the authorization and attestation section. Ensure the printed name, title, signature, and date are correctly completed to validate the application.
10. Once all sections are completed, save your changes. You can download, print, or share the completed application as needed.

Complete your application online today to take the next step in your credentialing process.